James, Patricia        dob 02/01/1926        77 & 1/12 y/o             3-2-03

941-0000                   000-0000 Hospital MR #00000


Mercy Folsom Hospital, Med Surg Ward

983-7460, Fax 983-7548, ooo@hospital1.com

Admission H&P


CC: 10 d cough and fever

HPI: 77 y/o admitted from the clinic with the above.  There was moderate shortness of breath and some L lateral pleuritic chest pain.  Other than as above, ROS neg: [HEENT: no vision changes nor eye problems; no nasal nor sinus sx; ears ok w/o hearing loss, changes or pain; mouth and teeth w/o sx; neck w/o sx.  GI: BM’s 5-8/week w/o blood or pain.  No nausea, vomiting, diarrhea nor constipation.. GU: no dysuria nor nocturia nor urine complaints.  Skin: no rashes nor other complaints.  Endo: no complaints.  Psych: no complaints.]

Exam: crackles & some dullness L lung base; HR 110/min, oximetry O2 sat 90%, 130/85; moderately toxic appearing; no murmurs, legs dry, no NVD.  [otherwise general female exam w/ only normal findings Except as above, there were only normal findings, including: NAD nontoxic, & normal physical: [heent: perrla fundii wnl; nasal mbs wnl; Tm's wnl; OP wnl; neck wnl; gi: nontender w/o HSKM; CVA nontender; neuromuscular exam grossly wnl w/o deficit; psych wnl; endo wnl; skin wnl]

A: pneumonia, COPD

P: wbc 17.8 w/ left shift; CMP wnl othewise; CXR LLL infiltrate; EKG wnl

see admission orders


Note: this table usually adds some information at each visit  http: //coremedicalconcepts.com

PMH: gyn hx infra, appy ~ 15 y/o; Crohn's; urinary incontinence but no fistula, just loss of angle per urology; seizure disorder, DJD neck, HH, COPD, recurrent UTI, monilial angular stomatitis, partial small bowel obstruction resection 1970, 1988; B12 injection need; no tobacco x ‘85; TIA ~’75, stroke? per Dr Goldstein hx

FH: no breast ca

Problem Progress List










Cholesterol  -  HDL










LDL  -- trigly










  ‘ “          weight ® 






























Ongoing Meds

Past meds used & notes about them below:


Dilantin 100 mg tid

x ‘85 for seizure


Estropipate 0.625 qd

(=ogen=orthoest); previously on premarin 2/98; TAH BSO ‘70, bladder suspension, wnl mammogram 9’98


Hcthz 25 mg q AM

x 02/00; previously, hcthz 25 mg q AM or dyazide x ‘95


K+ 8 meq qd

X 8/4/00



x 02/00; previously, lorazepam 0.5 mg 1-2 tid prn x ‘96; # 60 mr2 03/08/99


Prednisone 5 mg qd

x 1970


Pentasa 250 mg 4 qid

x 1/00; previously, azulfidine 500 mg 1-2 qid x 2/98; stopped 2/98; hx asacol 400 mg 2 tid ‘96; occl prednisone x 10 yrs; vit B12 injections 09/08/99


Quinine SO4 325 mg hs prn

x before ‘94; B12 q several months


Monthly B12 injection

stopped lomotil 1-2 qid if needed x years; #240 mr6  03/29/99


Darvocet N 100 1 q 4-6 hr prn pain max #30/mo

zantac 150 mg hs x ‘93; bentyl prn; occl lomotil; B12 1000 mg  IM 06/18/99


vicodin 5 mg q 4-6 hr prn pain max #30/mo

for neck pain, see MFH ER visit 05'01


Selected test results: cardiac w/u ETT + 8’95, echo heart Normal 7’95; gi Dr. Schneiderman 4/1/98; colon wnl except diverticulosis 5/12/98; wnl EKG and CXR ‘97; CBC sgot alk phos lipase wnl but UA and C&S + 03/99; urine C&S neg 03/29/99; CXR probable old histoplasmosis 06/99; R hip post-op pelvic changes noted, w/ diffuse osteopenia w/o advanced arthropathy 12/99; CBC ESR K+ giardia Ag stool O&P  C- difficile wnl 2'00; neck XR trace anterolisthesis C4 on 5, minimal DDD neck 8/00;  CBC CMP UA lipids ESR SPE & TSH wnl except ¯ K+ 3.3, FBS ­ 159 [Hgb A1C 5.6], & UTI sensitive to sulfa 8/00; wnl CXR neck XR & EKG MFH ER 05'01; XR L5-S1 DDD 10'01


ADR:  penicillin rash, macrobid & motrin gastritis    Immunizations: pneumovax & Td 5’95; flu 11/6/99 & 10/29/01


Office visit record:  ... ct’d

10/1/01 chronic LBP x '97 fall, psoas myalgia?, seborrheic keratosis L preauricular region, pointed L malar red papule

10/29/01 seborrheic keratosis, facial papule, flu & B12 shot

12/10/01 labyrinthitis, neck myalgia

1/2/02 Crohn’s



John Smith, MD